Direction of Payment

From IAQforms

==Authorization and Direction of Payment Form==BERTERA SUBARU 111 WESTON ST. HARTFORD, CT 06120 / 860.895.6500 / FEDERAL TAX ID # 272050361

This Authorization and Direction of Payment Form, along with a Contract, must be signed by the Insured (“you”) before BERTERA SUBARU,can begin services. The purpose of this form is to allow the Insurance Company to pay BERTERA SUBARU directly, for all services rendered, and not require payment from you unless for whatever reason the Insurance Company denies the claim during or upon completion of services rendered and/or the bill becomes delinquent. If this form is not signed by you, you understand that you will be responsible to make payment to BERTERA SUBARU as described in your BERTERA SUBARU.

This will authorize _______________________________________________________ (“Insurance Company”) to make direct payment to BERTERA SUBARU for their professional services, or to include the name of BERTERA SUBARU on any check or draft, issued in payment of this claim ___________________________________________ (claim identification number). In the event the Insurance Company pays you directly, you will assume full responsibility to make payment to BERTERA SUBARU as described in your Contract with BERTERA SUBARU.

By signing this form you understand that you will be responsible for any deductible the insurance company does not pay. You also understand that a $____ finance charge per month will be charged on any unpaid balance; $____ processing fee applied to bad-checks submitted for payment; and these and all legal and collection fees associated with non-payment are the responsibility of you, the Client.

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Insured’s Signature & Date

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Insured’s Signature (if there is not another name on insurance, ignore) & Date